Red Flags
- ST elevation ≥1 mm in 2 contiguous leads or new LBBB — immediate reperfusion (FMC-to-device ≤90 min direct, ≤120 min if transfer)[2]
- Cardiogenic shock complicating ACS — emergent PCI of culprit only; mechanical support if SCAI C/D/E[2]
- Out-of-hospital cardiac arrest with ROSC and STEMI on ECG — immediate cath lab; routine CT before angiography NOT recommended unless suspected non-coronary cause[2]
- Very-high-risk NSTE-ACS (haemodynamic instability, refractory ischaemia, life-threatening arrhythmia, mechanical complication) — immediate invasive (<2 h)[2]
First-line treatment
Interventions
- Primary PCI (preferred for STEMI)[2]FMC-to-device ≤90 min direct, ≤120 min if transfer; complete revascularisation during index admission preferred
- DAPT duration[2]Default 12 months DAPT post-ACS; shorten to 1–6 months in high bleeding risk (HBR) per ARC-HBR; extend with low-dose ticagrelor or rivaroxaban 2.5 mg BD in selected high-ischaemic-risk patients
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Aspirin[2] | Antiplatelet (loading) | 150–300 mg chewed at FMC then 75–100 mg daily | — | All ACS unless contraindicated |
| Prasugrel or ticagrelor[2] | P2Y12 inhibitor | Prasugrel 60 mg load then 10 mg daily; ticagrelor 180 mg load then 90 mg BD | — | Prasugrel preferred over ticagrelor in PCI-treated NSTE-ACS where coronary anatomy known (ISAR-REACT 5) |
| Atorvastatin[2] | High-intensity statin | 40–80 mg PO daily started in hospital | — | Add ezetimibe early per 2023 update for combination LDL-C lowering |
| Bisoprolol or carvedilol[2] | Beta-blocker | Bisoprolol 1.25–10 mg daily; carvedilol 3.125–25 mg BD; titrate post-stabilisation | — | Within 24 h if no contraindication |
| Ramipril or perindopril[2] | ACE inhibitor | Ramipril 1.25–5 mg BD; perindopril 4–8 mg daily | — | All ACS within 24 h, especially anterior MI, LVEF <40%, HF, diabetes, CKD |
| Unfractionated heparin or enoxaparin[2] | Parenteral anticoagulant | UFH 70–100 U/kg IV bolus during PCI; enoxaparin 1 mg/kg SC BD | — | Bivalirudin alternative; reduce enoxaparin if eGFR 15–30; UFH if eGFR <15 |
Aspirin[2]
Antiplatelet (loading)
- Adult
- 150–300 mg chewed at FMC then 75–100 mg daily
- Paediatric
- —
All ACS unless contraindicated
Prasugrel or ticagrelor[2]
P2Y12 inhibitor
- Adult
- Prasugrel 60 mg load then 10 mg daily; ticagrelor 180 mg load then 90 mg BD
- Paediatric
- —
Prasugrel preferred over ticagrelor in PCI-treated NSTE-ACS where coronary anatomy known (ISAR-REACT 5)
Atorvastatin[2]
High-intensity statin
- Adult
- 40–80 mg PO daily started in hospital
- Paediatric
- —
Add ezetimibe early per 2023 update for combination LDL-C lowering
Bisoprolol or carvedilol[2]
Beta-blocker
- Adult
- Bisoprolol 1.25–10 mg daily; carvedilol 3.125–25 mg BD; titrate post-stabilisation
- Paediatric
- —
Within 24 h if no contraindication
Ramipril or perindopril[2]
ACE inhibitor
- Adult
- Ramipril 1.25–5 mg BD; perindopril 4–8 mg daily
- Paediatric
- —
All ACS within 24 h, especially anterior MI, LVEF <40%, HF, diabetes, CKD
Unfractionated heparin or enoxaparin[2]
Parenteral anticoagulant
- Adult
- UFH 70–100 U/kg IV bolus during PCI; enoxaparin 1 mg/kg SC BD
- Paediatric
- —
Bivalirudin alternative; reduce enoxaparin if eGFR 15–30; UFH if eGFR <15
Safety-net
Referral criteria
- STEMI ECG diagnosticActivate cath lab; transfer to PCI-capable centre if not on-site[2]
- Cardiogenic shock or mechanical complicationHeart team; mechanical circulatory support consideration[2]
- Very-high-risk NSTE-ACSEmergency angiography <2 h[2]
- Post-ACS LVEF ≤35% at 40 days despite optimal therapyCardiology for ICD evaluation[2]
Clinical summary
European-perspective diagnosis, reperfusion, and post-ACS management combining STEMI and NSTE-ACS into a single framework.